NCG020019 DMR WW (3)

A
PROCESS/MINE DEWATERING WASTEWATER DISCHARGE MONITORING REPORT (DMR)
Please Mail Original And One Copy To Mailing Address Below
GENERAL, PERMIT NO. NCG020000
Part A • Facility Information
4
Samples Collected In Quarter: 1 (all samples shall be reported within 3 �ftillU2 4 3 �
nig monitoring period)
cap ee)
Certificate Of Coverage No. NCG02,-.-7dQ /,., i & F03 WUntly of Facility EaA J V--LIt J
Facility Name Nam o£ &aboratory 1L
Facility Contact tlb r w, a,e.5v cCt�1�R Jj (ification# �o?
Facility Contact Phone No. ( / q) - 3 79 DV`JR S�- i
Part B: Process Wastewater and Mine Dewatering Wastewater Monitoring Requirements
Number
Reteiving Stream Name
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I Measured continuously using a flow measuring device or estimated using manufacturer's pump curves and pump logs.
Part C. Certification
"I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a
system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person
or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best
of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information,
including the possibility of fines and imprisonment for knowing violations."
Ajz;�q 15 a6 1S
(Signatut'e of Per ee) (Date
Part D: Mailing Address
Attn: Central Files, DENR, N.C. Division of Water Quality, 1617 Mall Service Center, Raleigh, NC 27699-1617
S WU-244-012005